Racial and Ethnic Differences in Advance Directive Possession: Role of Demographic Factors, Religious Affiliation, and Personal Health Values in a National Survey of Older Adults

Abstract

Background: Black and Hispanic older Americans are less likely than white older Americans to possess advance directives. Understanding the reasons for this racial and ethnic difference is necessary to identify targets for future interventions to improve advance care planning in these populations. Methods: The aim of the study was to evaluate whether racial and ethnic differences in advance directive possession are explained by other demographic factors, religious characteristics, and personal health values. A general population survey was conducted in a nationally representative sample using a web-enabled survey panel of American adults aged 50 and older (n = 2154). Results: In a sample of older Americans, white participants are significantly more likely to possess advance directives (44.0%) than black older Americans (24.0%, p < 0.001) and Hispanic older Americans (29.0%, p = 0.006). Gender, age, retired or disabled employment status, educational attainment, religious affiliation, Internet access, preferences for physician-centered decision making, and desiring longevity regardless of functional status were independent predictors of advance directive possession. In fully adjusted multivariable models with all predictors included, black older Americans remained significantly less likely than white older Americans to have an advance directive (odds ratio [OR] = 0.42, 95% confidence interval [CI] = 0.24-0.75), whereas the effect of Hispanic ethnicity was no longer statistically significant (OR = 0.65, 95% CI = 0.39-1.1). Conclusion: In a nationally representative sample, black race is an independent predictor for advance directive possession. This association remains even after adjustment for other demographic variables, religious characteristics, and personal health values. These findings support targeted efforts to mitigate racial disparities in access to advance care planning.

Advance Directives in Patients Over 60 Years Old: Assessment of Perceived Value and Need For Education in the Outpatient Setting

“…Consistent with previous research, our data revealed strong associations between advance directive completion and racial/ethnic background, education, and marital status [15,16]. Being married or widowed was associated with advance directive possession, with widowed participants having the highest completion rate.…”

“…Significant attention has been paid to demographic and socioeconomic factors that may explain non-completion. With few exceptions, studies have reported lower completion rates among black, Hispanic and other non-white groups [15][16][17]. These same studies also found that lower education and socioeconomic status were associated with lower completion rates.…”

“…Completion rates improve with age [15,16] and declining health status [2] but close to 50% of those over the age of 65 still do not have an advance directive in place. Significant attention has been paid to demographic and socioeconomic factors that may explain non-completion.…”

A randomized clinical trial of adolescents with HIV/AIDS: pediatric advance care planning

“…Study results demonstrate access to a structured pACP program in hospital-based clinics was successful in engaging an underserved cohort of largely young, poor, non-college educated, African-American and Latino/Hispanic adolescents and their families, thereby overcoming barriers to EOL research in this group (Grady, 2005; Huang, Neuhaus, & Chiong, 2016; Johnstone & Kanitsaki, 2009) and health disparities in ACP (AARP, 2003; Arenella, 2016; Boucher, Raghavan, Smith, Arnold, & Johnson, 2016). Training facilitators to certification and providing structure overcame other barriers, including clinicians not knowing the right thing to say, concerns about parents having unrealistic expectations, and lack of parental readiness (Davies et al, 2008; Durall, Zurakowski, & Wolfe, 2012; Sudore & Fried, 2010).…”

Are older adults’ demographic characteristics social determinants of their perceived importance, desire, and ability to perform end‐of‐life self‐care actions?

“…Further exploration of the relationships between older adults’ perceptions related to their EOL planning and their religious and ethnic backgrounds could better promote patient‐centered care. For example, Huang, Neuhaus, and Chiong found that among American adults aged 50 years and older, black race was an independent predictor for completing an EOL plan after adjusting for other demographic variables such as age, gender, religious affiliations, and self‐care behaviors. Barriers and facilitators to EOL planning for older adults and health care providers (eg, communicating about sensitive topics related to EOL planning in such as home, outpatient, and palliative care settings) could be further explored …”